Treating a Gout Attack
A gout attack is a very painful event that can be at least partially relieved by immobilising the joint and applying an ice pack. Some natural medicines are effective in reducing the pain of the attack quickly and surely.
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What is the Origin of the Disease?
Gout is an extremely painful inflammatory disease of the joint. It is caused by an excessively high level of uric acid in the blood (hyperuricaemia), which forms crystals in the joint and soft tissue above a certain concentration (60mg/l (360 µmol/l)), causing an inflammatory reaction in the joint and in the tissue surrounding the joint: this is the gout attack. Gout is common in men over the age of 30, and in women after the menopause (often triggered by diuretic treatment for high blood pressure). The incidence of gout has almost doubled in recent years for a variety of reasons: increased life expectancy, increased obesity and its complications (cardiovascular disease), increased chronic kidney disease, unbalanced diet, use of many drugs.
The blood level of uric acid results from the difference between its production and elimination. The production of uric acid comes mainly from the functioning of the body’s cells and to a lesser extent from the diet. The elimination of uric acid is mainly carried out by the kidneys.
Excess uric acid is most often due to a defect in its elimination by the kidneys in the context of a family and hereditary disease (gout), sometimes to a kidney disease (causing renal failure). (1) Some drugs also reduce the elimination of uric acid by the kidneys (e.g. diuretics, low dose aspirin).
Excess uric acid can be promoted by diet. The three main foods that increase its production are:
– Beer (even without alcohol),
– hard liquor, and
– sugary sodas rich in fructose.
Triggering Factors
A gout attack can be triggered in different situations (1,2):
– Physical trauma (tight shoes, prolonged walking, shock),
– Stressful situations (stress, overwork, surgery),
– Infections (flu, pneumonia, acute bronchitis),
– Myocardial infarction, stroke,
– Sudden stop or start of certain drugs (aspirin, diuretics), including those used to reduce uricemia (allopurinol, febuxostat, probenecid, benzbromarone),
– Too low an intake of drinks (mainly water).
The Origin of Hyperuricaemia
Hyperuricaemia (blood uric acid level above 60 mg/l or 360 µmol/l) may be secondary to a defect in renal elimination and/or increased production of uric acid.
- Impaired renal elimination of uric acid
- An abnormality in the transport of uric acid in the kidney – due to a defect in the “uric acid pumps” located in the renal tubules (one of the components of the kidney). These defects are often hereditary, of genetic origin.
- Kidney failure with insufficient renal filtration (chronic renal failure).
- Taking certain drugs: diuretics, aspirin, ciclosporin (a drug used in organ transplants).
- Increased production of uric acid:
- Dietary origin:
– Foods whose breakdown leads to a high production of uric acid: beer (even WITHOUT alcohol), strong alcohols and sweetened drinks (sodas, colas, fruit juices rich in fructose);
– Too many foods rich in animal proteins (offal, meat, fish, seafood); - Cellular origin :
– Genetic abnormalities in the functioning of certain enzymes;
– Special situations (fasting, muscular effort);
– Chemotherapy.
- Dietary origin:
Certain diseases can accompany hyperuricaemia (arterial hypertension, obesity, diabetes, increased cholesterol and especially triglycerides…).
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How to treat a Gout Attack?
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The different forms of the Disease
Gout often appears as a familial and hereditary disease, limiting the elimination of uric acid by the kidney.
The excess uric acid that causes gout can have several causes, including
– a diet too rich in animal proteins,
– too much beer (even without alcohol), strong alcohol, or sweetened sodas,
– certain medications.
Mechanism of the Gout Attack
When the amount of uric acid in the blood is too high, above 60 mg/l or 360 µmol/l, it can form urate microcrystals in and/or around the joints. These microcrystals can cause an inflammatory reaction that lasts a few days.
The formation of urate microcrystals is favoured by lower temperatures, so the joints of the foot are preferably affected, especially the 1st joint (metatarsophalangeal) of the big toe.
A gout attack can be triggered by various situations such as shock, stress or the sudden withdrawal of certain medications.
Gout attacks are caused by cells in the body that are involved in the defence against microbes. Urate crystals are considered foreign aggressors to the body, which tries to eliminate them.
After ten days or more, for various reasons, and in particular the cessation of the release of anti-inflammatory substances, the vicious circle of the gout attack stops by itself in 5 to 10 days despite the persistence of crystals in the joint.
Joint Destruction and Tophus Formation
Without appropriate treatment of hyperuricaemia, gout attacks recur. The time frame varies, sometimes several years after the first attack, and without symptoms between attacks. Over time, crystals accumulate and painless lumps called tophus form in the bones, joints, tendons or under the skin. It takes an average of 11 years to develop into chronic gout.
Tophi in the joints can lead to new gout attacks. If left untreated, repeated attacks lead to deterioration of the affected joints, resulting in joint deformity and limited mobility and chronic pain.
In some people, excess uric acid is also accompanied by crystal deposition in the kidneys, leading to kidney stones and their consequence, renal colic attacks, and eventually to kidney complications such as renal failure.
What are the Manifestations of the Disease?
The onset of gout is very sudden and painful. The affected joint is swollen and red. In the long term and without appropriate treatment, the persistence of a too high level of uric acid in the blood leads to the formation of painless lumps, called tophus, in the joints and under the skin.
The first attack of gout usually affects only one joint in the lower limb. Sometimes several joints are affected at the same time, which is known as gouty arthritis. Other joints may be affected, such as the hands, wrists, elbows, and exceptionally the spine.
The manifestations are characterised by very strong joint pain. The joint appears swollen and purplish red. The violence of the pain is felt like a bone fracture or a bite. Walking is difficult. The pain prevents sleep. The crisis in the big toe is called podagra, which means having the foot caught in a wolf trap.
With resolution of the attack, over a few days, the skin of the toe peels off and may peel off like an onion skin. These signs may be associated with a moderate to high fever (up to 39°C), sometimes accompanied by chills, raising fears of a severe infection. At the end of the attack, the appearance of the joint returns to normal.
Tophus deposits form not only in the joints, in and around the bones, but also under the skin in places unrelated to the joint affected by the attacks, particularly in the cartilage of the auricle, the elbow (bursitis), the big toe, the heel…
These deposits, whether visible or not, can be observed approximately 10 to 20 years after the first attack. Kidney problems, particularly stones, are also common in people with untreated gout.
How is the Disease Diagnosed?
The signs of the disease are usually characteristic. When this is not the case, further tests may be necessary.
The typical gout attack is often easy to recognise. When this is not the case, various elements can help in the diagnosis: existence of gout in the parents or in the siblings, a history of renal colic with stones invisible on simple X-rays, cardiovascular diseases such as arterial hypertension, angina pectoris or infarction, a “metabolic syndrome”, with diabetes, cholesterol and/or triglyceride anomalies.
A blood test also provides diagnostic information by revealing:
– the existence of an excessively high uric acid level (hyperuricemia > 360 µmol/l or 60 mg/l), which is not always the case at the time of an attack;
– an increase in the blood sedimentation rate (ESR), an increase in the white blood cell count (WBC) and the CRP protein, which are characteristic of inflammation (but also of infection).
But the indisputable element for the diagnosis of a gout attack is the presence of urate crystals in the joint fluid. The doctor takes a small amount of joint fluid from the joint with a syringe. Microscopic examination allows the microcrystals to be identified easily and quickly. By reducing the volume of intra-articular fluid, the puncture also helps to reduce pain.
When the doctor cannot collect joint fluid, ultrasound of the affected joint may show signs suggestive of urate crystal deposition, such as a double contour sign or evidence of tophus.
Radiology does not help to diagnose gouty arthritis, but it is very useful to exclude another diagnosis, and to visualise the damage caused by the tophus on the joint and adjacent bones (known as gouty arthropathy).
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